Surgery Center Accreditation Standards
In order for your surgery center to become completely compliant to the Federal Medicare Regulations, these standards apply and must be fully compliant to the actual operations of your center. They, the surveyors, whether they are with the accreditation deem status or state Medicare folks, they will look to see that you are fully compliant in these as they are written in the federal regulations as such.
Facility abides by all applicable Residing State business & Professions codes. Facility abides by Bus & Prof. C. 650.01 and 650.02 (physician ownership and referral act of 1993). Facility and all principals, employees, etc. abide by all applicable Residing State and Federal laws. Facility must assure that physicians on staff follows MEDICAL BOARDS probation restrictions. Facility must report within 10 days to THE ACCREDITING AGENCY any adverse action taken against it. The owner physicians and medical director shall be responsible for all clinical decisions.
Medical Director job description. P and P1 designate a person responsible for day-to-day operations of the office and for management of fiscal matters. Scope of procedures is complete, appropriately performed and periodically reviewed. Facilities that use the same waiting area for both office and surgery center may have shared spaces if separate and exclusive schedules for use are determined. Clinical procedures for nurses and protocols for PA’s are developed and signed by physician owners and Med. Dir. Facility accreditation certificate is posted in a location visible to patients and staff. Name, phone number of accrediting agency and instructions for submission of complaints must be posted in a location readily visible to patients and staff. THE ACCREDITING AGENCY Notification of Accreditation Survey is posted 30 days prior to survey.
Patient information materials must be reviewed annually or when significant changes take place at facility. Patient Rights and Responsibilities are honored and respected, they must be posted in a location available to patients or provided to each patient in writing. Ensuring an Advanced Directives policy is in place that also allows for patient complaints and interpreter use.
Administration & Human Resources
The scheduling and prioritizing of appointments is based on the clinical needs of the patient. Scheduling and prioritizing of phone calls is based on the clinical needs of patient. 24-hour clinical coverage of the practice is necessary. Follow—up on cancelled or missed appointments based on the clinical need of patients. Center must use a uniform system and trained personnel for patient billing, with all payer types getting the same bill, ensuring that all are consistent and precise in codes and documentation. Personnel is responsible for making sure patients understand their fees, processing for authorization of services.
Staff are trained and supervised by qualified personnel. Provided orientation appropriate to job, including:
a. Confidentiality of patient info
b. Fires and life safety equipment and emergency drills
c. OSHA Blood-Borne Pathogen standards
d. Maintenance and operation of equipment within their scope of practice
Staff development (in-service) shall be provided based on findings from management studies and patient satisfaction surveys. Employee policies and procedures address:
a. Hiring and dismissal of staff
b. Performance expectations and competency
d. Expected working hours
e. Sexual harassment prohibitions
f. Patient privacy and confidentiality
g. Management of impaired practitioner
Responsibilities of staff are understood by health care providers, while wearing name tags with their first name and last name initial, and the credentials they hold (Aaron P., RN). Job descriptions in writing, signed off by the employee as understanding them and completely being in agreement of their responsibilities. Personnel files are maintained for all employees and include education, training and confidentiality statements. Documentation of allied health care professionals state licensure/certification is on site. Registry nurses or techs can be used, using the same process as hire, minus all of the financial and Human resources specific to your company info. Documentation of each independent practitioners state licensure and DEA registration is on site. Independent practitioner files must include verification of education, training board eligibility, etc. Physicians have current professional liability coverage.
Clinical privileges periodically re-apprised.
Medical staff establishes criteria and standards for admission to the organized medical staff.
Credentialing information is verified.
Frequencies for re-appointment to the staff are defined in bylaws.
Peer review determinations are included in credentials review.
Privileges are granted in accordance with recommendations from qualified health professionals.
Governing body reviews and approves clinical privileges.
Organized medical staff maintains onsite documentation of clinical privileges.
All members of medical staff are subject to proctoring.
Members of medical staff have developed criteria to grant, restrict and terminate privileges of independent health care practitioners.
Clinical privileges periodically re-appraised.
Quality Management and Peer Review
There must be an active QA / QI program and it must be viewed and reviewed annually to ensure it still meets the organization’s needs. Therefore, QM program reviewed, modified and approved at least annually by Med. Dir. Governing body and administration supports medical staff in efforts to improve quality of care.
3.4 Quality management program oversees:
a. Safety of patient and staff
b. Infection control
d. Risk management
f. Quality improvement and analysis
QM program has organized, integrated plan that addresses administrative and clinical outcomes and the Facility assesses patient satisfaction. Risk management programs are in place to help reduce or correct practices that jeopardize patient safety. QM program updates governing body on its activities and findings, providing a peer review process with its medical staff. Peer review activity is kept confidential, occurring at least annually. Expedited peer review of all deaths, unplanned transfer to acute facilities, complications and other unexpected events with adverse clinical outcomes. The results of peer review are considered when granting medical staff membership and clinical privileges. Medical staff bylaws are established standards for peer review. Peer review body meets on regular basis, at least quarterly and distributes findings.
The expedited review of deaths, etc. and notification to THE ACCREDITING AGENCY and CMS within 24 hours of death of patient who has had procedure within 7 days. Reports filed with Medical Board of CA and Nat’l Practitioner Data Bank as per your state law dictates only. Peer review results are considered when granting privileges.
Medical Records, a page & chart
Outpatient settings have a system for maintaining clinical records. Medical Record is legible, organized and complete. Patient ID number on each page of record is maintained with integrity. The medical records accessibility is monitored by job function and includes:
d. home and work phone numbers
e. Emergency contact info
f. Patient billing/insurance info
h. Notation of special circumstances (i.e. hearing impaired)
All material in the medical record is signed, dated and timed. Additions and corrections to medical record are clearly indicated with the reason for the change. All clinical records are completed within 30 days from date of service. Retention of medical records complies with applicable regulations. Medical record includes info needed to safely treat patients, including:
a. Allergy & Sensitivities that also includes the reaction if exposed
b. H & P
c. Immunization info
d. All known finding, diagnoses, treatments and documentation of physician’s review
e. Results of lab, x-rays, diagnostic studies, op reports, etc.
f. Problem list and treatment plan and current med list that is reconciled prior to discharge
g. Date and time of all health encounters in chronological order
h. Phone consultations when relevant
i. Prescription and refills record
k. Refusal of care, non-compliance notes and no-show record
l. Documented preventative care
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